Dr. David C. Ring of Massachusetts General Hospital was supposed to operate on the ring finger of a 65-year-old woman. Instead, he performed carpal tunnel surgery on her.
In an extraordinarily open admission, he describes what happened and how in the New England Journal of Medicine today. Several factors figured in, including switches in personnel and operating room, the fact that the patient did not speak English, and the fact that when the patient's arm was washed with alcohol, the pen marking that designated the surgical site was washed away.
(Got to love this comment on the msnbc.com account of this story: "Can someone please tell me why Mass. General can't afford permanent marker?")
The New England Journal piece describes the mistakes analyzed, the lessons learned and the improvements made since the incident. To me, the most amazing part of the story is that after Dr. Ring realized his mistake and quickly admitted it to the patient, she let him go back in and do the originally intended operation.
But research does find that when doctors apologize, patients tend to forgive them — and sue less often. And another comment on msnbc.com suggests Dr. Ring may be rewarded for his candor: "I think I would want this doctor operating on me - with his admissions I bet that he will be working extra hard to never have another mistake like this."
This program aired on November 11, 2010. The audio for this program is not available.